MAGIC BULLETS VS SYSTEMIC RECIPES - A HUMAN FACTORS STUDY FROM AIR TRAFFIC MANAGEMENT

摘要

An air traffic management operational centre in Europe was suffering from a recurrent incident pattern. This pattern involved controllers overlooking an aircraft that they had dealt with and handed over to the next sector, but it was still within their own sector of airspace. Over a period of around a year, more than a dozen incidents occurred where minimum separation was lost between such aircraft and other sector aircraft as a result of this omission. The situation was analysed from a Human Factors perspective and found to be caused by a working memory failure, where recent information was 'discarded' to make room for new aircraft information. The solution involved a change to the HMI to highlight that the aircraft were still relevant and must not be overlooked by the controller. After the change, the incident pattern disappeared for approximately two years. However, a new and more complex incident development has now occurred, and is also being analysed from a Human Factors perspective. This time there appears to be no simple remedy, and a more systemic approach is being used. The case study is presented, and the approaches of searching for 'magic bullet' solutions versus 'systemic' packages of recommendations are contrasted, and implications for ergonomists discussed.